2017; 21(Supl.1):1281-90 DOI: 10.1590/1807-57622016.0254
Users' perceptions on social impact of the colaboration project of the More Doctors
Program: a case study
Rafael Gustavo de Liz(a)
Rita de Cássia Gabrielli Souza Lima(b)
(a) Centro de Ciências da Saúde, Universidade Regional de Blumenau. Rua Antônio da Veiga, 140, Campus 1, Sala J-105. Itoupava. Blumenau, SC, Brasil. 89.012-900. rafael_deliz@yahoo.com.br
(b) Centro de Ciências da Saúde, Universidade do Vale do Itajaí. Itajaí, SC, Brasil. rita.lima@univali.br
The study presented in this paper identifies probable changes generated in the care process of a primary healthcare service in a municipality of Santa Catarina, Brazil, part of the Collaboration Project of the More Doctors Program. This was a qualitative study conducted in 2015 that employed semi-structured interviews and a field diary as data collection instruments. Data analysis was performed through the ethical-political method, revealing: a) consistent creation of caring relationships, mediated by a humanistic mode of thinking and practicing medicine and internalization among members of the community of the belief that they were being cared for by an equal who was also a human being; and b) insecurity regarding the project’s end, based on misinformation. This study concluded that a
solidary disposition is essential to the creation of caring relationships, and that the federal government needs to implement ethicalpolitical guidelines to ensure quality information about the project.
Keywords: Medical Care. Primary Care. Right to health.
2017; 21(Supl.1):1281-90
Unequal distribution of physicians in Brazilian primary health care is a historical
product of the development model adopted in the New Republic in 1985, following the
military dictatorship. Above all, it is a product of historical medical corporative hegemony1,
the productivity-focused perspective on education2 inherited from the dictatorship and the
biomedical sciences3. Thus, such inequity constitutes a social issue4.
Since the implementation of the National Primary Care Policy in 20065, the fight to
ensure primary medical care in unassisted Brazilian territories has continued. Unequal
distribution of this care, expressed in the historical reality of the map of Brazilian life,
exposes the current need to defend the right to health. However, besides defending victory
in the right to health, new battles must be fought to effectively implement this right. In
Brazil, the individual process of choosing a location rarely coincides with socially just
distribution, as most physicians choose more seductive “Brazils”6.
The emergency supply of primary care physicians ensured by Provisional Measure no.
621 of July 2013, in addition to the creation of the More Doctors Program (MDP) in July of
the same year7, can be understood as the recognition of the need for new initiatives that are
aimed at expanding the right to health. In particular, it was a response to the demands of
lower-middle-class youth in the 2013 protests8, and those of several mayors, in Brasilia,
also in 2013, who asked: “Where are the doctors?”9, Approved by the National Congress and
sanctioned by the Presidency of the Republic, Law no. 12.871, of October 22, 2013
implemented the MDP7.
Chapter IV of the More Doctors Program Law establishes the implementation of the
More Doctors in Brazil Project (MDBP). This project contemplates: a) physicians with degrees
earned in Brazil or foreign degrees validated in Brazil; b) Brazilian physicians who have
earned foreign diplomas and have been licensed to practice medicine abroad, and c) foreign
physicians licensed to practice medicine abroad7. Article 23 addresses the possibility of
2017; 21(Supl.1):1281-90
actions. According to the MDP webpage, as of May 2016, of the 295 municipalities in Santa
Catarina, 217 had received physicians through the MDP10.
The aim of this paper is to analyze, from the ethical-political perspective, how users
perceive the social impact of the MDBP in a municipality of 2,900 inhabitants in the
macro-region of Vale do Itajaí (Santa Catarina) that did not have primary healthcare physicians for
over a year(c) before the beginning of the project. Social impact is defined as “changes
produced through interventions in the context of real life11.”
Methodology
This was a qualitative, exploratory, and comprehensive single-case study12
conducted in a young municipality in the macro-region of Vale do Itajaí, Santa Catarina,
Brazil.
In its design, the interaction between factors and events was considered the central
nucleus13. The three phases that characterize a case study were followed: a) choice of a
theoretical framework14, selecting a case and designing data collection; b) conducting the
study, with data collection and exploration of transcribed material; and c) analysis based on
the selected theory, with data interpretation12.
This study was evaluated and approved by the Research Ethics Committee of the
University of Vale do Itajaí, Santa Catarina, carried out in accordance with Resolution, no.
466/2012 of the Brazilian National Health Council, Ministry of Health. This was an extension
of state research in progress, funded by the Foundation for Research and Innovation of the
State of Santa Catarina (Fapesc), Public Notice 2014/1, whose general objective was to
analyze the social impact of the More Doctors Program in Santa Catarina, from the
ethical-political perspective. Participant anonymity was ensured using code names based on authors
(c)
This i for atio was gathered fro the u i ipality’s i ter al hu a resour e re ords. After o tai i g per issio fro pu li
2017; 21(Supl.1):1281-90
from Brazilian literature.
Chosen by convenience, the sample consisted of 12 participants of various
professions, such as farmers, traders, independent professionals, and retirees, with different
levels of education (elementary, secondary and tertiary) and ages ranging from 23 to 82
years old. All had resided in the municipality for over 10 years; 7 were women, 5 were men,
and 8 had been born and raised in the municipality; 1 was pregnant and received prenatal
care from the unit; 3 had grandchildren, and all had had children.
The 12 users were indicated by the workers of the municipality’s primary care unit,
based on the following criteria: a) being over the age of 18 and cognitively competent; and
b) being a primary care unit user. The indicated users were contacted via telephone, followed
by home visits, when they were officially invited to participate and given informed consent
forms to sign. The users received information about the research in adequate and careful
language, and were made aware of the implied and procedural ethical issues of the study.
Data collection took place between November and December 2015. Semi-structured
interviews were chosen to gather data, as they allow for the inclusion of questions as
deemed necessary during data collection15. The interviews were conducted individually and
in private, lasting approximately one hour. The data were audio recorded and later
transcribed with ethical rigor.
The guiding axis of the interview script was: “What changed with the arrival of
physicians through the Program?”, developed in three themes: 1) User perceptions of medical
care; 2) establishment of relationships between physicians and the community and 3)
transformations in primary healthcare practices. Field diaries were kept throughout the
research process, which broadened the range of information, generating a “free and creative
flow process” for data processing and analysis16.
Based on the frameworks suggested by Minayo17,Assis18 and Gramsci19, content
2017; 21(Supl.1):1281-90
1. Data organization: Accurate transcriptions, followed by organization of the material
through codenames and free and thorough readings;
2. Data classification: Based on the empirical data, research objectives, and theoretical
assumptions, the central ideas in the nuclei of meaning were identified, classified as
Group I – caring relationships, or Group II – uncertainty about the end of the More
Doctors Program;
3. Categorization: Based on the intersection of the epistemological, instrumental, and
reflexive components of the central ideas (Group I/Group II): From “He’s so simple,
he’s part of the municipality, he doesn’t even seem like a doctor!” to “fear about the
project’s end”;
4. Analysis method: Data analysis employed the ethical-political method, which is based
on a reflexive-critical dimension of understanding, exploring how the arrival of a
physician through the MDBP, ensuring basic medical care, affected the primary care
of users. This method, which investigates how, is an adaptation of the humanist
method of analysis, called by Antonio Gramsci the “given that” method, whose
analysis is anchored in the historical dimension of reality and the interpretation of its
contradictory trends19.
Results and discussion
The category from “He’s so simple, part of the municipality, doesn’t even seem like a
doctor!” to“fear regarding the project’s end” represents the movement between the
elements that constitute the patient-physician relationship, a process generated through the
integration of social relationships. This category also expressed uncertainty due to the
2017; 21(Supl.1):1281-90
He’s so simple, he’s part of the municipality, he doesn’t even seem like a doctor!
(Casimiro de Abreu).
This program really helped our town. They say it’s going to end. I’m afraid. (Martha
Medeiros)
Participants expressed the idea that creating bonds requires a pedagogical
relationship, guided by humanistic values19. This category represents the prerequisite for
producing relationships in times when: the “inversion between means and ends” persists; the
dream of a dignified life still occupies the space of means of survival; money is not a means
to enjoy a dignified life, but an “end in and of itself”; and social relations are enslaved to an
anonymous system20 (economic, primarily). These relationships cannot be based on formal,
bureaucratic medical rationality21, but must be based on value-centered22 and ethical
rationality20, in which the use of collective values enables the production of
relationship-based care. Within the scope of this study, the values “being simple” and “physician”
presented by the Cuban physician generated the necessary social relationship for good
interactions between the caregiver, individuals receiving care, and the community.
When asked about their relationships with the physician supplied through the MDP,
users stated:
We are a simple people here, [...] most of us make a living in the fields, on farms, in
tobacco plantations [...] this doctor gets along well with the people because he
knows what they are like. (Martha Medeiros)
[...] He’s humble [...] Even though he’s not Brazilian, he’s already familiar with [...]
2017; 21(Supl.1):1281-90
According to the interviewees, the physician’swillingness to “know what the people
are like” created a bond with the local community, as they internalized the belief that they
were being cared for by an equal. Furthermore, on reflecting about the simplicity that
characterizes the community, the physician relates with the community at the human level,
expanding his field of possibilities for providing quality care. By showing humility and
familiarity with humble people, the physician broadened his scientific horizon, appropriating
the social determination of the health-illness process, and effectively shifted from
representing a professional from a given category (physician) to a “producer” of health19.
In this context, the population’s way of life and forming productive relationships
seem to compose the central axis of the work process. It is worth noting that the users
demonstrated awareness of health and illness as socially determined processes, which points
to the current need for recovering the social medicine movement of the 19th century23 to
establish quality work processes between physicians and users: quality resulting from a
focus on a caring patient-physician relationship.
In 1845, Engels demonstrated that the working class in several cities in England
established relationships through a capitalist process of production, which forced them to
lead uncertain lives. Inaugurating the theoretical model of social determination, his studies
demonstrated that the emptiness of the relationships between the working masses and
productive relationships were the determinants of work-related illnesses and physical and
moral nonexistence. To some extent, Engels reinforced what Bernardino Ramazzini had
already stated in 1700: The social condition of a given community, generated by its living
conditions, established through modes of social organization, determines the path toward
understanding individual and collective health and illness25.
An interview was conducted with the physician allocated to the studied municipality,
and showed that he was a Cuban physician who was not registered with the Brazilian Federal
2017; 21(Supl.1):1281-90
by the Pan American Health Organization and signed by Brazil and Cuba in 201326, supplied
through the MDP Collaboration Project.
The physician’s conduct was guided by “knowing how people are.” This leads to a
reflection about the place of humility and solidarity in the Brazilian and Cuban socialization
process. Within the scope of medical education, Cuba adopts a sociopolitical and
pedagogical culture, based on humanism and solidarity27. If solidarity is understood as a
social value that results from the encounter of individuals who recognize each other as
equals in their rights as citizens28, it is likely that the basis of Cuban life has been historically
based on solidary relationships, given the socialist dimension of the country’s historical
process: [...] Even though he’s not Brazilian, he knows the town [...] goes to the same places
we do; he’s always at community festivities (Cecília Meireles).
The Brazilian National Health System (SUS), which was established at the 8th National
Health Conference in 1986, was based on socialist principles. Several factors explain its
current unsustainability, related to the inability of the capitalist mode of production to: a)
materialize health as a universal right; b) provide comprehensiveness when ensuring
universal right to health; and c) break with historical inequities in health distribution as a
right for all.
This social victory and its guarantees have developed as a process. The fight for the
right to health dates back to the 1960s, during the military dictatorship, and is still occurring
in the present. The health system reform movement and popular organizations have gained
momentum. In 2013, for example, the June protests and the March of Mayors to Brasilia with
the slogan “Where are the doctors?”6 resulted in an important social response from the state:
the emergency provision of the More Doctors Program.
This progressive battle has reaffirmed an important axis relative to the state’s
(political and civil society) understanding of the need for collective will29 to effectively ensure
the right to health and form autonomous28 subjects30 capable of making decisions about
2017; 21(Supl.1):1281-90
Thus, in an individualized society such as Brazil, the concept of risk has priority over
the concrete production of health and healthy social relationships, such as those expressed
between the Cuban physician and users. In this context, political actions seem to be acting
as a kind of conscience that considers the historical need to ensure health in the territory
based on the production of citizens, “in light of reality and life”31. This reality highlights the
epistemological ground in which bonds are democratically created: the encounter of people
who recognize themselves as equals in their citizenship. This constitutes democratic and
permeable epistemology, based on the democratic value of health production.
Imbued with this role, the physician was not only an instrument of a collaboration
agreement who went to the municipality out of professional interest and for income
possibilities, to care for the sick, request tests and prescribe medications. His attitude was
one of a promoter of health, someone who belonged to the community and was willing to fill
a current void: interaction. This context of social interaction composed of close bonds is the
prerequisite for the possibility of establishing patient-physician relationships: “He’s part of
the municipality [...] (Aluísio de Azevedo); [...] He gets along well with the people (Casimiro
de Abreu)”.
It is important to state once again that this municipality went over a year with no
primary care physicians before the emergency provision of the MDP. This context, in which
medical care and the local population were not dominated by the biomedical model, favored
the establishment of bonds. The presence of these bonds paved the way for an “ethics of
recognition”30,28 in the public sphere of primary care: Users recognized each other and the
physician as citizens having rights that are part of a universal totality, based on the motto of
health as a democratic value that is a right for all.
In this type of bond, in which the local population constructs the theoretical model
for medical care, which is a social determination, care is a product of concrete social actions,
generated by equally concrete social players and through specific historical processes. In this
2017; 21(Supl.1):1281-90
way of life gains medical continence and medicalization ends up operating in its positive
biopolitical character: promoting a culture of shared medical care.
Another issue that came up in the interviews was the security generated by the
consolidation of the relationship. When physicians take part in and are part of the local
context, representing the social environment and the lives of people under their care, and
being part of their daily relationships, a sense of security is transmitted to the population. In
other words, the hallway meetings in life strengthen affective, personal, family, and work
relationships and generate sociability that mitigates the sense of risk. This result, coupled
with the guarantee of health as a democratic value, enables residents to feel they are
completely healthy, even in the presence of high blood pressure or diabetes, for example.
In 2007, a study was conducted in the province of Rome, Italy, with the goal of
investigating the relationships between health and society in the context of Italian family
medicine. The researchers found that the production of caring relationships between family
physicians and service users found fertile ground in small municipalities, in which life
“hurries up slowly.” Contrary to the results from metropolitan and industrial areas, villages
demonstrated that the production of care took place based on a specific idea of temporality
that legitimizes horizontal solidary relationships33. In such relationships, users are respected
in their freedom to make decisions about their own health care6. This study corroborates the
data from the present investigation, as shown in the following excerpt:
Our municipality is small, people know each other, visit each other, work together.
If you treat them well, they sing your praises. And that’s what happened with this
doctor. (José de Alencar)
Physicians hold performative authority, making potentially strong performative
statements to convince users to act in favor of instrumental solutions in their health-illness
2017; 21(Supl.1):1281-90
depended on his way of being, which favored the emergence of people confident in their
cultural capital34.
The analysis of this category reinforces that any approach to health care, instituted in
any given historical era, is the result of the style of thought circulating in the context of
those historical, social, and cultural relationships. According to this logic, the humanistic
approach used by the physician in this study, and his willingness to establish relationships,
were a result of his style of thought, created at a given historical moment in his life. This
historical moment corresponds exactly with a time that had previously conditioned and
established the horizon that could be contemplated by him: practicing humanistic and
solidary medicine. By guiding the relationship between the physician and users, these
characteristics resulted in an approach that legitimized how the local community understood
health: as horizontal and democratic35.
Thus, the relationship demonstrated by the community with the collaborating
physician nurtured the hegemony of social determination. In other words, the understanding
of health on the part of the physician and the community, in practice, became the baseline
for ensuring care: the supremacy of social determination became the dominant style36 of
medical care. In this consistent approach to care, the probable limitations imposed by the
physical and technological structure of the primary care service, in addition to the macro
context, in which municipal resources suffer the effects of the ethical, political, and
economic crises occurring in Brazil, flowed in the human horizon in a village with time for
life.
In the daily life of the relationships in the studied social space, the patient-physician
relationship was not limited to discourse, but represented a social construction based upon
the encounter of individuals, in which no person is subjugated36; an ethical-political
encounter. The basis of this mode of encounter can be perceived through the excerpt “works
at the health center,” which was not expressed in a demeaning manner, but with a subtle
2017; 21(Supl.1):1281-90
However, participants also stated:
They say that [the project] is going to end. I’m afraid [...]. At my age, I can’t leave in
the middle of the night to go to another town for a consultation. [...] Before this
doctor, I had leave at three in the morning from my house to get an appointment
somewhere else. (Martha Medeiros)
This dialectical relationship is a historical and social issue, as synthetically described
above: the interference of the concept of risk linked to probabilistic life in the concrete
production of health, socially determined by the conditions of the possibilities of the present
time. The population could not fully enjoy the victory of receiving medical care without the
threat of the project ending. This flow between security brought by presence, and insecurity
caused by the threat of absence, represented a negative element in the health of the local
population. This insecurity is rooted in a risk-based society37, a society that masterfully
conditions the health of present time to the uncertainties of tomorrow. This understanding
allows for the deduction that even though health continence in the territory provided by the
physician was an ethical good, systemic pressure was exerted by the dominant mode of
thought of capitalist societies: unpredictability.
It is important to highlight that the fear of losing humanistic, democratic,
comprehensive, and solidary medical care ends up weakening the work process in primary
care. This could be overcome if the ministries responsible for the emergency provision
effectively provided quality information. For example, as institutional subjects, the
supervisors of collaborating physicians could qualify the right to information. Thus, they
could communicate that in 2018, when the collaboration agreement is terminated, Brazil
excepts to have trained residents to replace the staff supplied by the emergency measure.
Access to quality information opens broad avenues and constitutes a social right.
2017; 21(Supl.1):1281-90
experienced in primary care territories has limited the ability of those services to meet the
concrete health needs of the territory38. This social factor requires critical reflection and
positioning, i.e., the architects of this emergency provision need to treat the initiative
ethically, clarifying the meaning, objective and duration of the program.
If users were familiar with the meaning of emergency provision and aware of the
duration of the agreement and to what extent they may face dark times (regarding the
transition between the end of the collaboration agreement between Brazil and Cuba and the
arrival of residents), this sense of risk could be mitigated. The problem is that the process of
policy and program implementation follows a path of limited communication. This is the
course of events in a time that does not allow time for sharing information.
The municipality received its primary care unit in 1998, which was the year of its
emancipation. According to local records, primary medical care was the responsibility of 19
physicians between 1997 and 2014, an average of one physician each year. At some times
during this period, the local community had no physicians available. This turnover rate, and
the occasional absence of medical care, probably generated a social representation of the
risk of lack of available care. This risk produced overwhelming materiality: “leave at three in
the morning from my house to get an appointment somewhere else (Martha Medeiros)”.
In a context of macro ethical, political, and economic crises, the risk of losing
physicians is maximized, haunting the social space of primary care:
I’m afraid of when the program ends! Today we have a professional here,
right...When the program is over, who’s to say there’ll be a doctor? (Machado de
Assis)
With every passing day he wins over more residents [...], when he leaves he will be
2017; 21(Supl.1):1281-90
The participants expressed feelings of insecurity and the unpredictability of facing
life based on the uncertainty of tomorrow. The guaranteed presence of a physician who
resided in the municipality provided comfort and security to the population of this town,
ensuring an essential dimension of comprehensiveness of care: understanding the dynamics
of the territory.
The results showed that the participants viewed the collaborating physician as a
social victory for the territory. He was positively assessed by the community, not because of
his mere presence or resume, but because of the solidary personal relationships he
established with municipal residents.
Bernardino Fantini, director of the History of Medicine and Health Institute of the
Faculty of Medicine at the University of Geneva, masterfully explained the ideas about
medical care presented by Giovanni Berlinguer, Italian physician, bioethicist, politician, and
humanist. Berlinguer dedicated his life to the fight against “the dramatic realities” associated
with health, labor, and law, and viewed medical care as an architectonic space of production
and application of medical awareness, a humanistic exercise (ethics) in the face of daily
(political) decision-making, with solidarity at its core25.
Final considerations
The present study sought to understand the qualitative social impact of the
emergency supply of physicians provided through the MDP Collaboration Project on the care
process for residents of a small municipality of Santa Catarina, Brazil, which had suffered
from a lack of physicians in health services for over a year. The data showed that the
physician adopted a humanistic and solidary style of thought regarding medical care, in
which health is socially determined. He was willing to get to know the population, favoring
the creation of bonds, as this willingness helped the community internalize the belief that
2017; 21(Supl.1):1281-90
simple.” This relationship was not present merely in discourse, but also represented a social
construction of the ethical-political encounter. This encounter, which was based on a way of
thinking and practicing medicine presented by a legitimate producer of health, the
collaborating physician, has been presented as the epistemological ground for having an
emancipatory impact in the life of users, since they showed confidence in their daily
relationships with their caregiver. However, fear of losing this medical care, which was a
result of misinformation about the MDP process, resulted in social insecurity, which
generated suffering. This suffering can be overcome with the implementation of
ethical-political guidelines by the federal government to ensure the right to information about the
actions of the MDP regarding the future of emergency provision, described in the program’s
law.
Collaborators
RG De Liz collaborated in the study conception and design, actively participated in the discussion of
the results, and contributed to the approval of the final version for publication. RCGS Lima collaborated
in the study conception and design, actively participated in the discussion of the results and revision of
the manuscript and contributed to the approval of the final version for publication.
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